2018–2019

Student Accident
Insurance Plans
Why you need
Student Insurance . . .
 Your school does not provide medical
insurance to cover injuries to students.
Instead, your school suggests this Plan to
provide affordable coverage options.
 If you don’t have other insurance, this
Student Accident Plan is essential.
K–12 Student Accident  Even if you do have other insurance, you
Insurance Plans will probably have to pay deductibles or
co-payments. This Student Accident Plan
will help to fill those expensive “gaps.”
 Only one yearly premium payment
required!
 Don’t wait until you’re faced with costly
medical bills to think about insurance.
 Read this information and make your
selections today!

Choose from these school approved plans . . .

 24-Hour Plan
  School-time Plan
– plus –
  Extended Dental Plan
  Football Plan
(Fall and NEW Spring Coverage Available)

UNDERWRITTEN BY: SERVICED BY:

COMMERCIAL TRAVELERS GENE WEBER AGENCY, INC.
LIFE INSURANCE COMPANY P.O. Box 120997
Commercial Travelers Building W. Melbourne, FL 32912-0997
Utica, NY 13502 (321) 637-0035 office
As Policy Form Series No’s: Public School CTP-7 (GWP) (321) 676-8685 fax
Private School CTP-7 (PR/CS) www.geneweberagency.com
OLP-GW-PIV-MB 18 paul@geneweberagency.com
39
 1 Choose from these School-Approved Plans:
24-Hour Plan
The student is insured for full 24-hour a day protection, for school-time accidents, and at home or away—at play—
at camp—on vacation—scouting—amateur sports—youth group activities—or just playing in the neighborhood.
Coverage for interscholastic tackle football played in or with grades 9–12 must be purchased separately. The
24-Hour Plan is available for a full year (annual coverage) or Summer Only.

School-time Plan
The student is insured while attending school when school is in session; participating in or attending activities spon-
sored solely by the school and directly and continuously supervised by a school official or employee, including all
sports except interscholastic tackle football played in or with grades 9–12 (unless you purchase football coverage) as
well as travel by school-furnished transportation during the school term; traveling to or from the Insured’s residence
and the school for regular school sessions; and attending religious classes, including travel.

Football Coverage
Covers injuries caused by accidents occurring while participating in interscholastic tackle football played in or
with grades 9–12, or while traveling as a team member in a school-provided vehicle to or from football games or
practice, when such travel is sponsored by the school and supervised by school employees. Fall & Spring Football
Coverage may only be purchased in combination with either the
Annual 24-Hour or School-time Coverage. Football Coverage may not be purchased by itself.

Extended Dental Plan

Increases the Dental Treatment Benefit under the Plans to a maximum of $1,000.00 per tooth for
accidental injury to one or more sound, natural teeth. This extended coverage is effective 24 hours a day
even when selected with School-time Coverage and ends on the opening day of school for the following
Fall term. Premium for the Extended Dental Benefit is $6.00 under all plans. Extended Dental Coverage
may not be purchased by itself.

2 Additional facts about the Plans:

Effective and Expiration Dates: School-time or 24-Hour coverage goes into effect on the day following
the envelope postmark date, but in no event prior to the opening day of school (or the first day of
Summer break for Summer Only coverage). The expiration date of coverage under the School-time
Plan is the close of the regular nine-month school term, except while the Insured is attending academ-
ic classroom sessions, exclusively sponsored and solely supervised by the school during the Summer.
24-Hour coverage ends on the opening day of school for the following Fall term. Football Coverage starts
the first day of regularly-scheduled school-sponsored practice, provided premium is paid prior to that date.
Football Coverage expires August 1, 2019.
Student Accident Insurance covers accidental bodily injury sustained during the term of insurance and
which causes loss directly and independently of all other causes. Insurance is good anywhere. For exam-
ple, if the student buys the Plan at school and the family moves, coverage will continue until the close of
the school term at any new public or parochial day school. There is no limit to the number of accidents a
student can have paid under the Policy.

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 3 Your choice of benefits
The Policy will pay up to $25,000.00, for medical expenses incurred as the result of covered injuries sustained
by an Insured in any one accident which occurs on or after the effective date of coverage. Benefits will be paid
for treatment, care and service performed within 52 weeks after the date of accident, not to exceed the Expense
Benefit Limitations stated below, provided the first such expense is incurred within 30 days after the accident.
All benefits are per accident, unless otherwise specified.
Expense Benefit Limitations—Benefits are paid up to the following maximums:

High Option Low Option

Hospital Inpatient Expense Room
and Board $250.00 per day $150.00 per day
Hospital Ancillary Charges $1,500.00 per accident $750 per accident
Hospital Outpatient Emergency Care
Expense (within 72 hours of injury) $75.00 per accident $40.00 per accident
Hospital Outpatient Surgery $250.00 per accident $150.00 per accident
Physician Expenses (Non-surgical) $30.00 per visit $20.00 per visit
Where treatment principally involves
physiotherapy, limited to 3 visits 3 visits
Physician Expenses (Surgical) $130.00 per unit allowance $90.00 per unit allowance
under the current California under the current California
Relative Value Studies, Relative Value Studies,
up to $800.00 per accident up to $500.00 per accident
Assistant Surgeon’s Expense 20% of Surgeon’s allowance 20% of Surgeon’s allowance
Anesthetist Expense 25% of Surgeon’s allowance 25% of Surgeon’s allowance
Private Duty Nursing Expense 80% of charges 80% of charges
Outpatient X-Ray Expense $100.00 per accident $50.00 per accident
Outpatient Laboratory Expense $50.00 per accident $25.00 per accident
Dental Treatment of Sound and
Natural Teeth $100.00 per tooth; up to $100.00 per tooth; up to
$300.00 per accident $300.00 per accident
Ambulance Expense $100.00 per accident $100.00 per accident
Aggravation or Re-Injury Expense $500.00 per accident $500.00 per accident
Injury Caused by Motor Vehicle, Expense $500.00 per accident $500.00 per accident
Diagnostic Surgery Expense $500.00 per accident $500.00 per accident
Diagnostic Imaging Expense $200.00 per accident $100.00 per accident

AD&D Benefits
Benefits are payable IN ADDITION to Medical Expense Benefits. If a covered injury causes loss within 100 days of
the accident, the policy will pay:
Loss of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2,000.00
Loss of both hands, both feet or both eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10,000.00
Loss of one hand or one foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,000.00
Loss of one hand and one foot; or one hand and one eye;
or one foot and one eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,000.00
Loss of sight of one eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,500.00

GW-PIV-18

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 Exclusions
These plans do not cover, nor is any premium charged for: (1) Injuries resulting from the practice or play of
interscholastic tackle football in or with grades 9–12, unless the proper additional premium per player has been
paid; or skiing in any form, except as a covered member of an interscholastic skiing team, or when 24-Hour
coverage is purchased; Summer recreational and camp programs unless 24-Hour coverage is purchased.
(2) Eyeglasses or contact lenses or prescriptions therefor; or drugs and medications, except when hospital
confined; or braces, orthopedic appliances, orthodontics or durable medical equipment. (3) Intentionally self-
inflicted injury; or injuries occurring while violating or attempting to violate any duly enacted law. (4) Illness, disease
or infection in any form, except pyogenic infection or bacterial infection due to accidental ingestion of contaminated
material; hernia in any form, unless due to a covered accident. (5) Treatment administered by any person employed
or retained by the school or by a member of the Insured’s immediate family. (6) Injuries sustained while operating,
riding in or on, or alighting from a 2- or 3-wheeled engine-driven or motorized vehicle, or any vehicle not designed
primarily for use on public streets and highways. (7) For accidents involving other motor vehicles, medical expenses
in excess of $500.00. (8) Air travel or the use of any device or equipment for aerial navigation, except as a fare-paying
passenger on a regularly-scheduled commercial airline. (9) Loss covered by Workers’ Compensation or Employer’s
Liability Act or Law. (10) Injury resulting from intoxication or the use of drugs or narcotics, unless administered on the
advice of a physician. (11) Injuries resulting from war or act of war, participation in any riot or civil commotion; nuclear
reaction or radiation. (12) Reinjury or complications of a condition due to accidental bodily injury occurring prior to the
effective date of coverage in excess of $500.00.

Limitations
Limitations: (1) No benefits are payable for any expense resulting from participation in interscholastic activities
for which benefits would be payable, in the absence of insurance hereunder, under any High School Association
Catastrophe Sports Accident Policy. (2) Under surgery, the maximum payment for multiple procedures performed
within the same operative field shall be limited to 150% of the amount payable for the primary procedure. (3) In the
event the Insured sustains an injury for which benefits are payable under more than one Student Accident Insurance
Plan or like coverage issued by Commercial Travelers, coverage shall be deemed to be in effect only under one such
coverage, the one affording the greater (or greatest) amount of benefits for the injury.
Note: Certain exclusions or limitations may be modified to meet individual state requirements.

How to file a claim

In case of an accident, simplified claim forms are available at the school. Accidents must be reported and bills
submitted within 90 days. If the student is insured under the “24-Hour Plan” and school is not in session, or
has transferred to another school, a claim form can be obtained from the Service Office on the cover, or from
www.studentplanscenter.com.

This is not the Policy. Rather, it is a brief description of the benefits and other provisions of the Policy. The Policy is governed
by the laws and regulations of the state in which it is issued and is subject to any necessary state approvals. Any provision
of the Policy, as described herein, that may be in conflict with the laws of the state where the school is located will be
administered to conform with the requirements of that state’s laws, including those relating to mandated benefits.
This plan is not available in all states.

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 4 How to apply
 Choose the plan best suited to your needs.
 Complete and sign the attached enrollment form.
 Enclose check or money order payable to Commercial Travelers for the required yearly premium.
 Mail to: Gene Weber Agency • P.O. Box 120997 • W. Melbourne, FL 32912-0997
IMPORTANT Keep this information as a Summary of Benefits. Complete provisions are contained in the Master Policy on file at
the school. It is subject to Insurance Department approval and will conform to the laws of the state where your school is located.
Individual policies will not be sent to you.
LATE ENROLLMENT Coverage may be purchased at any time during the school year, but there is no premium reduction for late
enrollment.
CANCELLATION Coverage is non-cancellable and premiums will not be pro-rated or refunded.
RETURN OF CHECK BY BANK Coverage will be immediately invalidated if check is returned by bank for any reason.

 CUT AND MAIL

Enrollment Form
Yearly Student Rates—2018–2019—Check Your Selections
BENEFIT OPTIONS
COVERAGE PLANS  High Option  Low Option
Annual 24-Hour (Includes School-time coverage)  $ 67.00  $35.00
School-time  $ 18.00  $ 8.00
Summer Only 24-Hour  $ 33.00  $12.00
*Extended Dental  $ 6.00  $ 6.00
*Football—Fall & Spring (Grades 9–12 only)  $130.00  $68.00
*Football—Spring Only (Grades 8–11 only)  $ 44.00  $23.00
Total Payment Enclosed $ $
*Note: Football Coverage is available only in combination with Annual 24-Hour or School-time Coverage. Extended Dental Coverage is available in combination with
24-Hour or Schooltime Coverage.
Make Check or Money Order Payable to “COMMERCIAL TRAVELERS” DO NOT SEND CASH
Please print child’s name clearly—1 letter to a box—ALL CAPITALS
STUDENT’S LAST NAME STUDENT’S FIRST NAME MIDDLE INITIAL

GRADE BIRTHDATE (Mo/Day/Yr)

PARENT’S NAME
HOME
ADDRESS
No. & Street Apt. # City State Zip

NAME OF SCHOOL
SCHOOL DISTRICT OR ADDRESS (CITY)
City State
I acknowledge that I have read the fraud warning on page 6.

SIGNATURE
(Parent or Guardian) Date Signed
39 EF-GW-PIV-18

 IMPORTANT! THIS IS YOUR INSURANCE CARD. IF COVERAGE IS PURCHASED CLIP, FOLD AND CARRY AS YOUR VERIFICATION OF COVERAGE.

This card verifies student accident coverage during the 2018–2019 school year for: List Medical Conditions:

Name of student

Name of school
Family Physician:
Plan Number GW-PIV Phone ( )
FOLD

Fully Insured & Underwritten by Commercial Travelers Insurance Company Coverage Purchased:
Send completed claim form and itemized bills to: COMMERCIAL TRAVELERS,
Attn: School Claims • 70 Genesee St. • Utica, NY 13502  Accident Only Coverage
studentplanscenter.com • 1-800-756-3702  24-Hour  Dental
Possession of this card does not guarantee eligibility. The student must be
enrolled in the plan. Eligibility is subject to Verification by Plan Administrator.  School-time  Football

5
AK, DE, IA, MI, MS, SC, WI: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any
materially false or misleading information is guilty of insurance fraud.
AL: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
AZ: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraud-
ulent claim for payment of a loss is subject to criminal and civil penalties.
GA, NE, VT: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false
or misleading information may be guilty of insurance fraud.
KY: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing
any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent
insurance act, which is a crime.
OH: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement is guilty of insurance fraud.
PA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement
of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
TN: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the
company. Penalties include imprisonment, fines and denial of insurance benefits.